GW1-2022-00292_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
1104 14.WATER ZONES
�/=-1 PROM I TO DESCRIPTION
Well Contactor Name
NC Well Contactor Cenifivaton Number .L 15.OUTER CASING far T!gb dwN6 OR WNER a
WO ;" 1 ' l T ^ 1 PROM ft. TO ft. DIAMETER In �oh, MA Ma
Company Name 1•taS -v,1
' l /A� Z \ IC INNER CASING OR Tt/BING clused-609)Well Construction Permit#: l 1/ / I d PROM TO DIAMETER TTIICKNFSS MATERIAL
List all applicable well construction permits(fs.OTC,C'ouruy.SYme, ariunce,etc.) ft. ft. in.
3.Well Use(check well use): ft' I ft" in.
Water Supply Wetio 17.SCREEN
PPY FROM I TO I DIAMETER I SLOT SIZE I TTHE N .S MATERIAL
Agricultural OM paUPublic tt. n. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft• ft, in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri IIOn FROM TO MALE EMPLACEME MEIN Da WIT
Non-Water Supply Well: fL h. O
Mcnitonng DRecovery
Injection Wen:
Aquifer Recharge OGmundwater Remediation
If.SANDIGRAVEL PACK ifs kable
Aquifer Storage and Recovery ❑Salinity Banter MOM TO MATERIAL I EMPLACEMENT METROD
Aquifer Test OStonnwater Drainage ft. rt.
Experimental Technology OSubsidence Control fl. ft.
Geothermal(Closed Loop) OTmcer 26.DRILLING LOG(a additional sheets,If nee
Geothermal(HeatinglCooling Return) Other ex lain under#21 Remarks) mom To DescRlPrum .nmr n.rea wevrven a�
f� \ ft. TO
4.Date Well(s)Completed:ll—�l- ad5 Well ID# N- R-
Sa.Well Location: EL ti l'l.
s-- �- a •� �1
DvAA e J ti It. rr11 -
Facility/Owner Name Fppac(�ifi i ity Me(fappliceble) It. ft.
'1Cr �/
�J P10&'A',qdAi �jfi ICV. Dutkwl r1(/ f. R.
Physkal Address,City,and Zip JN7 7 o R ft. .r safQ._lOG �e
21.REM
County Parcel Identification No.(PIN)
t t
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrvra:
(if well field,am taN sufficient)
ong is sucient) 22.Certification:36CY31r5939 t' N79°d' DIYo'' W
6.Is(are)the well(s)[Di/.—tit or OTearpmary Silialiture of Certified Well Contact/� Date
By signing this form.I hereby cer�y thm the wills)wsu(were)constructed in accordance
7.Is,this a repair to ao¢lasting well: 014-1 or ONo with 15A NCAC 02C 0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill ow kwwn well construction information and espla/n the nature of the copy oftMs record has been provided to the welt inviter.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprabe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: q J� SUBMITTALINSTRUMONS
9.Total well depth below land surface: ' l)l ) (ttd 24a. For All Wells: Submit this form Within 30 days of completion of well
For andople wells list all depths if different(trample-3Q200'atnd 2Q100') construction to the following'
10.Static water level below top of easing: 3 V (fl.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"'" 1617 Mail Service Center,Raleigh,NC 27699-1617
e
11.Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e auger,rotary,cable,direct push,eoe.)
Division of Water Resomoes,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
M.Yield(gpm) Method of test: 24c.For Water Supply& Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N� f�l Amount 6 l011, C completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016